1. Utilizing telemedicine to reach rural communities for specialty care
Amy Vierhile, DNP, RN, PPCNP-BC
Child Neurology
University of Rochester Medical Center

3. What is telemedicine? Also known as telehealth
Use of technology to deliver care or obtain medical information
First used in the Civil War
Took off in the 1990s for remote areas such as Alaska
Comparable outcomes to standard in-person visits
Transmitted casuality lists; Washington, Alaska, Idaho and Montana collaborative to deliver care

4. Platforms for telemedicine
Remote monitoring of vital signs, BGs
“Store and forward images”
Videoconsults for patient care
Apps used to track and transmit symptoms
Deliver an educational program
Docking stations, Nasa used telemetry and cardiac monitoring units in 1969 when astronauts landed on the moon, store and forward is taking images and transmitting, apps for psychiatry

5. Telemedicine examples
Fortney et al (2015)- veterans with PTSD randomized to receive usual therapy sessions or telemedicine sessions
114 received standard care, 111 received telemedicine care
6 month follow up, veterans who received telemedicine had 5.31 point decrease in PTSD symptoms; usual care had 1.07 point decrease
Those who received therapy via telemedicine had 18 times higher odds of initiating therapy and 8 times higher odds of completing at least 8 sessions

6. Telemedicine examples, continued…
Southard, Newfield and Laws (2014) randomized 62 patients to receive mental health evaluations via telemedicine or in-person
Psychiatrists had been driving to rural medical centers to evaluate patients
Those patients who were seen via telemedicine had a mean time to consult of 2.4 hours; those seen in person had a mean time to consult of 14.2 hours

7. Telemedicine examples, continued…
Program in Oregon to assess newborns at 5 remote hospitals via telemedicine (Scheans, 2014)
Able to recommend transport to NICU, cooling, obtain physician input as needed
70 babies evaluated in 2 years, faster time to transport and cooling

8. Telemedicine examples, continued…
Three rural practices in Scotland connected adolescents with psychiatrist in Edinburgh (Grealish, Hunter, Glaze and Potter, 2005)
All providers trained on equipment
Enrolled only 5 out of 65 potential patients
Providers cited lack of regular use which led to discomfort with process
Adolescents and their families liked the service

9. Telemedicine examples, continued…
Group of NPs in Delmarva peninsula, saw a need for Parkinson disease clinic (Pretzer-Aboff and Prettyman, 2015)
All trained in disease state, contracted with neurologist from NY, psychologist from NJ to deliver care
First 6 months, 36 patients seen remotely
Added speech, PT, mental health and support groups in standard clinic

10. Patient Satisfaction Patients highly satisfied (Myers et al., 2008)
Providers in remote areas less isolated (Bonney et al., 2015)
Increased compliance with appointments, 92% telemedicine appts kept vs 87% in person, 4.2% no-shows vs 7.8% in person (Leigh, Cruz & Mallios, 2009)
Therapy sessions can be successfully conducted (Boydell, Volpe and Pignatiello, 2010)
Satisfaction does not equate to efficacy
Improved access to care, convenience, less time missed from work and school, fewer transportation costs; Bonney and colleagues 100 providers in isolated areas of Australia connecting with 8 large medical centers, rural providers felt more connected to bigger cities, increased retention, using it to train residents and for experiential learning; increased compliance because visits are closer; many instances of psychiatry services delivered via telemedicine, adolescents view it as cool;

11. Barriers
Concerns over confidentiality of care (George, Hamilton & Baker, 2010)
Costs/time: equipment, personnel, credentialing, licensure, IT support (Weschler et al., 2015)
Less “connection” with patients (Pignatiello et al, 2012)
“Over-referral” of complex cases (Myers, Vander Stoep & Lobdell, 2013)
Proficiency in learning equipment, insufficient training, lack of comfort (Martin et al, 2012)
Minorities more distrustful of care delivered via telemedicine; importance of eye contact when using telemedicine- etiquette; insufficient training led to abandonment even though patients liked it

12. Program Development
Yellowlees (2005)- principles for successful adoption- select sites pragmatically, user-friendly technology, well-trained team
Empower stakeholders, administrative support critical (Boydell et al., 2004)
Training is critical (Gifford et al, 2012)
Planning and collaborative effort needed, identify a “champion” at both sites (Myers et al., 2010)

13. American Telemedicine Association
Covers U.S., reports on state legislative policy
Annual conference in May with vendors, speakers
Suggest developing a road map ahead of time.

15. Why telemedicine in child neurology?
Shortage of child neurologists; 1 for every 100,000 children by 2022 (Bale et al.,2009)
Neurology NPs can fill gap (Freeman et al, 2013)
Fewer child neurologists outside of metropolitan areas in many states (Velasquez & Chaves-Carballo, 2016)
Rural residents more dependent public assistance, travel greater distances (MacDowell et al., 2010)
As of January, 2016, all New York State insurances reimburse telemedicine visits
30-40% shortage by 2022; rural residents poorer, less employment opportunities, need car and gas money to get to appointments

16. Local Problem
Large catchment area. Monroe County 201 census 744, 340 people, area covers 1.6 million people; 8,000 outpatient visits per year, 50% live outside Monroe County, 25% live more than 2 counties away; 14 MDs, 6 NPs who see HA, epilepsy, ADHD and Tourette

17. Establishing telemedicine
Know your state
What is reimbursement?
Licensure?
Setting?
Hub vs. spoke?
NYS has reimbursement for visits now; licensure within state only, NYS has to be a doctor’s office (medical center) to another medical center

18. Telemedicine logistics
Pick your population
News or follow ups?
What diagnoses?
Hands on examination needed?
Determine reimbursement
Insurance vs. grant funding
Who will your partner be?
Health center, private practice, need numbers
Start slow, ease into practice

19. Planning Business agreement, contract
Who will purchase equipment, obtain licenses? What equipment is needed?
Live vs. store and forward
HIPAA security
IT support
Business plan, cost evaluation; sign a legal contract; Zoom vs Jabber; dedicated IT support each site; initial referrals, paperwork, scheduling reminders

20. Prior to implementation
Identify the team and champions
Test connectivity of equipment, audio/video quality
IT available to troubleshoot
Hold team meetings via telemedicine
“Mock patient” scenario
Phone contacts at both offices
Debriefing after telecommunication contacts regarding quality of audio/video

21. Developing a work plan
List process from beginning to end- referral, visit, notes and follow up
Determine who will be hub vs. spoke
Presenting provider or nurse? Train them on the exam
Determine what equipment you need- stethoscope, otoscope
Who will write prescriptions? Is a note generated?
Who generates the patient schedule?

23. Current telemedicine program
Partner with FLCH 5 offices
Telemedicine nurse in PCP office, patient navigator
They send referral to specialist, mark for review as telemedicine
FLCH does all scheduling for telemedicine blocks
Once appointment is made, patient navigator completes paperwork with family
Patient checks in at PCP office, vital signs, height and weight obtained

24. Current telemedicine program, continued…
We have dedicated telemedicine office, patient seen in PCP exam room
Nurse or provider assists with visit, neuro exam
Patient is on exam table, large monitor on cart for them to see specialist provider
Generate visit note, specialist prescribes
If family has an issue before next visit, call specialist directly
Spoke site can bill for RN time using GT modifier code

25. Strengths
Equipment is easy to use, nurses and families feel comfortable Visits are straightforward Scheduling flexibility Generated hub site income- $90 per visit charged to insurance; spoke site income $30 per visit for RN
In clinic no show rate 13%, Involvement of specialist typical for headache patients, in-person would have been $128 per visit, $2828 overall but have overhead, room rent, patient care techs, etc.

26. Limitations Connection concerns Telestethoscope
Spoke site staffing- need a dedicated nurse
Time commitment
Need to be able to problem solve this; time commitment is on the part of the spoke site

27. Recommendations Make sure everyone is on board
Acknowledge time commitment- can staff do something else while you are interviewing the family?
Back up plan for staff shortages
Billing on both ends
Process is easily transferrable, applicable to many settings
Sustainable

28. Future endeavors
15 million Americans received some sort of remote health in 2016 (
Improved reimbursement
Technologic advances
Peer-to-peer networks
mHealth
Integrating telemedicine into the EMR; partners join together to share their remote medical resources or PCPs consult with specialists sending dermatology pictures for example and then giving care back to their patient

29. Conclusions Telemedicine as we see it now is just the beginning
Allows us to reach a larger audience
Requires some coordination but easy to use
“ If we can remove 50% of the people taking time off work and arranging for child care so they can sit in a waiting room just to receive a diagnosis… it makes the health care system more efficient.” Nate Gladwell, director of the University of Utah telehealth program

30. QUESTIONS?